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4:06 pm
Sun March 30, 2014

Everybody Has A Price: Why This 'Invincible' Chose Insurance

Originally published on Tue April 1, 2014 5:30 pm

When we first met Brad Stevens, he was living in Lakeport, Calif., a struggling massage therapist in a struggling town on the southern tip of Clear Lake. Stevens had been uninsured his entire adult life, and used to believe firmly that clean living and exercise could stave off any need for medical care. But after a bicycle accident that injured his shoulder, and a battle with advanced thyroid cancer, Stevens was anxious last fall to enroll in some form of insurance — any kind of insurance — under the Affordable Care Act.

"I talked to an insurance guy who is selling Obamacare, and found out I don't qualify," Stevens said when we first talked to him last November. "What I'm going to get is Medi-Cal — California's Medicaid program."

The insurance broker had warned about long wait times. But when Stevens called the toll-free line for Covered California, the state's insurance marketplace, "I waited four minutes," he says. "It was a piece of cake."

The operator didn't offer to help him apply for Medi-Cal, but instead told Stevens to call his county's social services office.

"It wasn't a one-stop shop," Stevens says.

When he finally called the county office on Jan. 6, he was worried he might own too much stuff to qualify — that his two aging cars and the modest home he had bought long ago from his mother would count against him. That's a common concern; some rules about property and Medi-Cal qualification changed under the Affordable Care Act.

Sure enough, the forms that arrived in the mail asked for details about his bank account and any cars he owned. "So I called them back up and said, 'You don't need half of this stuff that you're requesting.' They said, 'Yes, you're right. That's an old form. We haven't switched over.' "

On Jan. 23, Stevens collected his records and made the half-hour drive down to the county social services office. "They were really efficient at the office," Stevens says, sounding surprised. He says of the county worker, "She was like, Boom! Boom! Boom! She's been doing this 10 years. I was just signing stuff." The county worker told him to expect the Medi-Cal enrollment process to take 45 days.

When we next talked on Feb. 7, Stevens was anxious to get his insurance card. He needed to refill his thyroid medication — he has no thyroid and relies on medication to keep his body functioning. His pharmacist told him the company that makes his pills had raised the price from $12.99 to $68. "I'm down to 24 pills right now, so I'm counting them daily," he told us. "If I haven't gotten my [Medi-Cal] number before I'm out of pills, I'm going to call Wal-Mart to find out what their price is."

There were other concerns if his Medi-Cal didn't kick in soon: To monitor his thyroid condition, Stevens has to get his blood drawn every year. In the years following his thyroid cancer, he could get the blood work done for $50 to $60 (he always paid cash), but now that same service was costing him $200. "It's gone astronomical," he told us.

With only a few thyroid pills left — and still no Medi-Cal confirmation — Stevens went to Wal-Mart and was able to get his prescription filled for $10 in cash. It's a different brand than he's used to, and he says it makes him more irritable and restless at night.

"The medication I get at Wal-Mart isn't as good as the medication I get here at the pharmacy in Lakeport," he says. The brand stocked at his local pharmacy, while now much more expensive, "keeps me really level. ... I find [that with] the stuff from the pharmacy at Wal-Mart, I do more fluctuations — moods and more [nights with] night sweats. More heart palpitations."

At the beginning of March, a Lake County case worker called Stevens to tell him his Medi-Cal was active. "Basically it took two months, from start to finish," Stevens says.

"Now that I'm covered, I want a physical, and a regular checkup that normal people [who have] insurance get. And I want to get a colonoscopy," Stevens says, laughing at his own enthusiasm for the unpleasant procedure.

It's been a few years since Stevens has seen a specialist about his thyroid. The last specialist, at the University of California, San Francisco, charged him $2,500 for an hourlong visit. "It was super expensive," Stevens says. "And I ran out of money." Now that he's enrolled in Medi-Cal, Stevens plans to call his primary care doctor soon to make an appointment and search for a specialist in his rural region.

Even though the card still hasn't arrived, he says being accepted into Medi-Cal is an extraordinary relief. "It's an incredible peace of mind," Stevens says. "I'm going, 'Yee-haw!' "

This story is part of a partnership with NPR and Kaiser Health News.

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.

Transcript

KELLY MCEVERS, HOST:

This is ALL THINGS CONSIDERED from NPR West. I'm Kelly McEvers, in for Arun Rath.

Tomorrow is the deadline to begin an application for health insurance under the Affordable Care Act. This week, the Obama administration announced more than six million people have signed up for private health insurance and another 3.5 million are thought to have received coverage through the Medicaid expansion in some states.

So we were wondering how are all these new patients going to affect the existing health care system. It's our cover story for today: How the Affordable Care Act is changing the lives of doctors and patients.

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MCEVERS: Let's start with the patients. We contacted dozens of people who've already tried to sign up for health care. The experiences were mixed. Carolyn Hackwell from Colchester, Vermont, was diagnosed with multiple sclerosis seven years ago. She just signed up for a new health care plan.

CAROLYN HACKWELL: My medication, like most MS medication, costs in the neighborhood of about $6,000 a month.

MCEVERS: Like her old plan, the new insurance pays for most of that. But now, there's no lifetime limit for her treatment. She pays about the same premium as before, but her deductible is lower.

HACKWELL: Better coverage, lower deductibles, no lifetime limits, allowance for pre-existing conditions. I'm amazed at how much better our health care situation is.

MCEVERS: Not everyone is happy with their new plans. As it was for so many people, the signup process was bumpy for Erin Moyse of St. Petersburg, Florida, waiting on hold, error messages. And when she did finally get logged in...

ERIN MOYSE: The plans are much more expensive than the plan that I was previously on. The bare minimum plan was over $100 a month more than what I was paying before.

MCEVERS: Plus, she says, she can't find any in-network doctors.

MOYSE: Something that I had no idea was even going to be a problem. You know, I just thought once I had coverage, I was - I had coverage and I'd be fine.

MCEVERS: In some states, people can sign up and are offered coverage, but they can't afford it, like Kathleen Payne. She's 26 and a full-time student in Utah. Her state didn't opt to expand Medicaid. Without this assistance, she says, she can't afford a new plan.

KATHLEEN PAYNE: It's like luck of the draw. I happen to live in Utah. Until I can graduate college and get a great job, I'm kind of stuck here.

MCEVERS: Payne was covered under her mom's health insurance, but then she aged out. She says she has an auto-immune thyroid disease that's now gone untreated for more than a year.

PAYNE: I could go into thyroid storm at any time and need to go to the ER and have no money to pay for hospitalization or medication. And I'm terrified that I'll get sick and won't be able to do anything about it.

MCEVERS: Mary Szyhowski works for a small business in St. Louis that doesn't provide health care. She couldn't afford her own insurance, so she went uninsured for five years. She just signed up in January and says she loves her new plan.

MARY SZYHOWSKI: I am thrilled that I now have insurance. I feel like it's a new lease on life.

MCEVERS: For the newly insured like Szyhowski, who've been away from the doctor's office for years, they have to start from scratch - physicals, blood work, medical history. Some new patients have medical problems they didn't even know about. Millions of new patients, what effect will they have on the system? Sarah Varney reports on people who are seeing a regular doctor for the very first time.

SARAH VARNEY, BYLINE: It's a bright warm morning on the shores of Clear Lake in Northern California.

BRAD STEVENS: I saw the biggest flock of geese fly over yesterday.

VARNEY: Birds are chirping in the fruit trees, the tulips are blooming, and Brad Stevens could not be more excited to get a colonoscopy.

STEVENS: Oh, yeah, it's an incredible peace of mind. I'm going, yee-haw. I mean, this is just fantastic.

VARNEY: The last time Brad, who is 59, had health insurance, Gerald Ford was in the White House. Brad always had low-paying jobs that didn't come with coverage, and he couldn't afford it on his own. He relied on vitamins and vigorous gym workouts to stay healthy but was laid low a few years ago by advanced thyroid cancer. He got help covering his cancer surgeries and radiation but has struggled to pay for medication and to see a thyroid specialist.

STEVENS: It was costing me $2,500 to see him for an hour. And I just - I ran out of money.

VARNEY: So earlier this month when a county worker called to tell Brad he'd been accepted into expanded Medicaid, he was thrilled. No longer would he have to count pills or pay out of pocket for expensive blood work, and he could finally play catch up on his preventive screenings.

STEVENS: Now that I'm covered I'm going, OK, I want to get a physical and get a regular checkup that normal people that have insurance get, you know? And I want to get a colonoscopy.

VARNEY: In the four years since the Affordable Care Act was passed by Congress, actuaries and anxious insurance executives have tried to gauge the magnitude of pent-up demand unleashed by the law's unprecedented expansion.

For clues to that answer, Dylan Roby, an assistant professor at UCLA, looked at a California program that provided coverage for three years to some 200,000 previously uninsured low-income people.

DYLAN ROBY: We saw that there was a short-term increase in pent-up demand in that they started using ER services, started using more outpatient services and were able to get more prescription drugs and were kind of dealing with health care needs that had been - they'd been waiting on and delaying.

VARNEY: By the second and third year, though, demand for medical services leveled off.

ROBY: They usually hit a point where they look a lot more like a typical insured person.

VARNEY: Insurance companies, analysts say, made similar assumptions about the new insurance market. People with chronic illnesses or festering injuries, for example, who couldn't get coverage now can sign up. And there's every expectation that they will seek treatment. Publicly, insurers say it's too soon to draw conclusions about medical trends, and they can't decipher yet who is newly covered. But privately, some insurers have been surprised by the degree of unmet needs.

TOM SNOOK: One of my clients said they had an enrollee who enrolled on a Monday and had a transplant on a Thursday.

VARNEY: Tom Snook is a principal with Milliman, an actuarial firm that works with insurance companies. He says a number of his clients have also reported a higher proportion of HIV enrollees. Insurance companies factored in about two to 3 percent higher costs in their first year due to pent-up demand, says Snook. Similar to the California experiment, a Milliman study also found a short spike in demand that tailed off. But that is a temporary phenomenon.

SNOOK: Well, the bigger issue is the overall permanent morbidity of people enrolling under the ACA under an open enrollment, especially the previously uninsured.

VARNEY: Permanent morbidity, insurance speak for transplant patients, cancer patients, chronic pain sufferers, costly customers for years to come. But as for the question of pent-up demand, actuaries say there may be customers who come roaring in for care, get what they need and then aren't heard from again for a while.

MCEVERS: Sarah Varney's report comes to us from Kaiser Health News, a nonprofit news service.

Three is one place in the country that already has experience with this pent-up demand: Massachusetts, where a statewide affordable care plan was put in place in 2006 known as Romneycare after then Governor Mitt Romney. The plan eventually brought hundreds of thousands of previously uninsured people into the health care system.

We asked Dr. Peter Smulowitz, an emergency physician at Beth Israel Deaconess Medical Center in Boston, what we can learn from his state's experience.

Dr. Smulowitz, we wanted to ask you kind of a dumb question first. Under, you know, the Romneycare plan, Massachusetts has its own health care law. And so we've been wondering why Massachusetts residents would even need the Affordable Care Act.

DR. PETER SMULOWITZ: In reality, most of the Affordable Care Act is not so applicable to Massachusetts residents mainly for the reason that you mentioned, which is the Affordable Care Act was modeled directly after the original Massachusetts health care reform. So since that has gone into effect, we've had a sharp decrease in the percent of uninsured in Massachusetts. And we started a little bit lower than the rest of the country. Approximately 10 percent of the population was uninsured. And the last I checked they were probably around two to 3 percent of the population of Massachusetts were uninsured.

MCEVERS: Well, you recently did a study on emergency room use after the Massachusetts health care law went into place. You found that from 2004 to 2009, there was a small but kind of steady increase in patients going to the emergency room. Why was that?

SMULOWITZ: As people gain access to health insurance, they don't have to worry about the cost of care as much anymore. So if they really need to seek care, they can do that, be that at their primary care physician or an emergency department. And that leads into the second primary reason, which is if people simply cannot access their primary care physicians either because they're - they just don't have a primary care physician or there's not enough primary care physicians to fit everybody in in a timely fashion, then the safety net for the health care system is the emergency department.

So I would expect and anticipate that emergency department use across the country will be even higher than what we saw in Massachusetts after the Affordable Care Act is fully implemented.

MCEVERS: Is there a concern that pent-up demand won't just mean that doctors won't be able to take on new patients, but there might not be enough doctors to go around?

SMULOWITZ: Well, there's no doubt about that. And unfortunately, it really is distributed to comparisons between the more affluent areas and lower socioeconomic areas. Those are the areas where there's less access to primary care.

MCEVERS: Just because there's - the doctors aren't moving to those places.

SMULOWITZ: That's right. There's really no financial incentive for physicians to really build up in those areas. Now, we have made great strides in expanding things like community health centers, but until primary care is really properly rewarded in this country, we're never going to have a full system that serves everybody equally.

MCEVERS: What has it been like to get all these new patients who haven't been to the doctor in years now that they have health care?

SMULOWITZ: As an emergency physician, I've always prided myself on just taking care of anybody. It's fascinating to hear people's stories about what they've gone through for years of never having had access to health care. And finally, once they get insurance, they just don't have to worry about how much something's going to cost. If they need care, they can access to it.

MCEVERS: Dr. Peter Smulowitz is an emergency physician at Beth Israel Deaconess Medical Center in Boston. Dr. Smulowitz, thank you.

SMULOWITZ: Appreciate your time. Thank you for having me.

MCEVERS: Remember, tomorrow is the deadline to start the process to sign up for health care and avoid tax penalties.

There are a few exceptions. If you're eligible for Medicaid or the Children's Insurance Program, if you've had a big life change, a move, married or divorced, got or lost a job, or if you have a problem with the process like your information didn't make it to the insurance company, you have more time.

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MCEVERS: This is NPR News. Transcript provided by NPR, Copyright NPR.

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